Challenges of managing dementia in a hospital setting

Abstract

Aim: The aim of this review is to examine the challenges of managing dementia in a hospital

setting.

Background: There are more people living over the 65 years in the UK today than they were a

few years ago. As life expectancy increases so does the number of people with dementia. Every

year, over 100,000 people die from dementia. Dementia is chronic illness that progresses over

the years and has no cure. During the advanced stage of dementia, people need special care that

can be provided best in a hospital setting. Hence, admissions of people with dementia have also

increased over the years.

Methods: A review of articles that were published post 2010 in English and relating to the issue

of challenging of managing dementia in a hospital setting.

Findings: Four five themes emerged in this review. Communication issues between the nurses,

patients and family caregivers, lack of understanding of dementia among nursing staff due to

inadequate training, problematic behavior of patients with dementia due to unfamiliar

environment, stigmatization and inappropriate medical interventions.

Conclusion: This review establishes the importance of educating nursing staff regarding

dementia so that they can provide quality care to patients. It also shows the importance of

building strong relationships among the staff, patients and caregivers through effective

communication.
1. Introduction

Life expectancy is increasing all over Europe. Demographic trends indicate that the number of

older people in the UK will increase over the next twenty years particularly among older people

aged over 85 years (Wilkinson, 2011). Today, more and more people in the UK are living beyond

65 years despite the fact that most are unable to access health and social services. As a result, the

number of people with dementia has also increased in the UK given that the incidence of

dementia is one in five in people aged 85 years (Wilkinson, 2011). Thus, the higher the number

of older people, the higher the incidence of dementia. Dementia is considered a terminal illness

that progresses with age and currently has no cure. However, the progression varies from one

patient to another with prognosis that ranges from 2 to over 15 years. The end-stage of dementia

may last for two to three years.

People with dementia are aged 65 years and above are hospitalized more than people suffering

from other health conditions. This can be attributed to several factors such as trouble managing

existing medical conditions at home. Also, dementia makes it difficult for patients to take

medication on time or even alert caregivers of new symptoms at home. A person with dementia

is at a high risk of developing serious conditions such as stroke and pneumonia; hence the need

for hospitalization. The caring for dementia patients in a hospital setting brings several

challenges for the hospital staff, the family caregivers and the patient as well. Therefore, efforts

need to be made to overcome these challenges in order to provide quality care to dementia

patients.

This literature review consists of 7 sections. The first section is the introduction which provides a

little background of the research problem and an outline of how the extended literature review
will progress. The second section presents the focus questions and the rationale of the study. The

third section presents the methodology used to gather information for this review. This includes

the inclusion and exclusion criteria used when selecting articles for review. The fourth section

presents thematic analysis in which critical discussions of the emerging themes from the selected

articles have been presented. The strengths and limitations of the study have been presented in

the fifth section. In the sixth section, implications for practice have been presented along with

future recommendations. A critical discussion of the findings obtained from the review has also

been provided. The seven section presents the conclusion where key points of the review have

been summarized.

2. Focus question and rationale

2.1. Focus question

The aim of this review is to examine the challenges of managing dementia in a hospital setting.

In order to achieve this, the review will focus on answering these questions

1. What challenges do nursing staff face when managing patients with dementia in a

hospital setting?

2. What challenges do patients with dementia face in a hospital setting?

3. What challenges do family caregivers of patients with dementia face when providing care

assistance in a hospital setting?

This review will therefore seek to achieve the following objectives

1. To discuss the challenges that nursing staff face when managing patients with dementia in

a hospital setting
 2. To investigate challenges that dementia patients face in a hospital setting

3. To explore challenges that family caregivers of patients with dementia face when

providing care assistance in a hospital setting

2.2. Rationale

As at 2001, the number of people with dementia across the world was estimated to be 24 million

and was expected to keep doubling after every 20 years. Dementia is a term used to refer to a

number of clinical changes which affect the human brain. According to Bridges and Wilkinson

(2011), dementia is a progressive and incurable brain disorder among the elderly people that

causes cognitive impairment such as use of verbal language, memory, mobility, information, and

difficulties in the day-to-day and social activities. The risk of developing dementia increases with

age and hence the elderly people aged 65 years and above are the most affected. In the UK, the

incidence of dementia is 1 in 1000 people below 65 years and 1 in 5 people above 85 years.

There are various types of dementia and each presents varying symptoms. They include

Alzheimers disease, mixed dementia, vascular dementia, dementia with Lewy bodies (DLB),

Parkinsons disease, and frontotemporal dementia among others. Alzheimers disease and

vascular dementia are the most common types of dementia.

Cowdell (2010) explains that dementia causes impairment of intellectual functioning, which

interferers with a persons normal activities as well as relationships. With time, people with

dementia may start to show changes in their personality along with behavioral issues, loss of

memory and inability to solve problems effectively. These devastating effects of dementia put a

toll not only on the individuals but also on their family members and the health care systems as a

whole. The physical ailments associated with dementia, which mainly affect the elderly like
coronary heart disease, hypertension, stroke and diabetes, bring a lot of challenges when caring

for people with dementia. Other ailments such as urinary tract infections, chest infections and fall

and fractures are also common among people with dementia. This increases the need for acute

medical care, which can be best provided in a hospital setting.

According to a report by Alzheimers Association, people with dementia are hospitalized as

many as three times more than people without dementia (Alzheimers Association, 2011). In

addition, they tend to stay in the hospital longer than people without dementia thereby increasing

costs for patients. Alzheimers Association (2011) found that patients with dementia occupy

about a quarter of all hospital beds at any given time. As the ageing population continues to

increase, the number of dementia patients in hospitals is likely increase as well. According to

James (2011), dementia patients require more hours of nursing care since their functionality is

likely to decrease during admission thereby leading to permanent decline in health as increase in

costs.

James (2011) argues that an acute hospital setting presents several challenges to both nurses and

dementia patients. Dementia patients have impaired cognitive ability; hence, they find an

unfamiliar environment to be frightening, unsettling and confusing. Hospitals are usually very

busy with a lot of noise and confusing places. Lack of clear signage, high level of noise and

bright lighting can be quite disorienting to the people with dementia. For instance, wards in the

hospital usually have identical doorways and beds, which add to the dementia patients confusion

and distress. As a result, the confusion increases their disorientation thereby making them more

aggressive and withdrawn. This further makes the nurses job more challenging when trying to

maintain the patient personal hygiene, proper nutrition and administer drugs because the patient

is unable to recognize the environment, familiar faces, and daily routines.

Not much research has been done to investigate these challenges and how they should be tackled

hence the need for this review. Therefore, the information obtained through this will help to

provide suggestions for nursing practice as well as increase the pool of literature available

regarding the challenges faced in managing dementia in a hospital setting. Moreover, the review

will establish a base for further research in to the subject of caring for patients with dementia in

an acute hospital setting.

3. Methodology

The data for this study was gathered through an integrated review of relevant literature regarding

dementia patients in a hospital setting. Three databases were used to provide qualitative data

regarding the research subject. These were MEDLINE, Cumulative Index to Nursing and Allied

Health Literature (CINAHL), and PsycINFO. Peer reviewed articles that focused people with

dementia in a hospital setting were selected. The inclusion criteria included only articles that

were published in English, published after 2010, and had information relating to people with

dementia in a hospital setting. The exclusion criteria included any article that was published

earlier than 2010, articles that were not written in English even if they contained relevant

information, and articles that contained information about patients with early onset of dementia.

The keywords used to search for these information included dementia patients, Alzheimers,

elderly, acute care environment, acute and hospital setting. The table below is a summary of

findings from each search strategy consisting of the database, search strategy, number of article

and no of relevant articles.

Table 1: Search strategy

Database Search strategy No. of articles No. of relevant No. of articles that
 articles met the criteria

MEDLINE Dementia, elderly, 50 28 4

hospital

CINAHL Alzheimers, acute 53 22 5

PsychINFO Dementia patients, 57 26 5

acute care

environment

Reference lists of Dementia, acute 70 44 6

selected articles hospital setting,

elderly

Total 230 120 20

At first, the search focused on obtaining information regarding challenges that nurses face when

managing dementia in a hospital setting. However, this did not yield enough articles for review

therefore the search criteria was broadened to include challenges that patients with dementia face

when in a hospital setting. Furthermore, the reference lists from the identified articles were also

reviewed to provide more sources of relevant information. The initial search yielded 230 articles

but after removal of articles that did not have relevant information, a total of 120 articles were

identified. These articles were further reviewed and only 20 met the inclusion criteria. The

findings in the articles ware organized in an evidence table below so as to help in identifying

gaps in literature. The evidence table includes the article author and title, purpose, sample size,

study design, key findings and nursing implications.

Table 2: Table of evidence

 Purpose Sample Study Key findings Nursing implications
Author/Title
size design

al. To explore the Patients Grounde Three categories Awareness of the

Evardsson et
psychosocial climate in pysco- d theory emerged in relation intimate connection
(2012)

the and its influence on the geriatric design to the core category; between staff presence
Forecasting

ward climate: a well-being of people ward 'sharing place and and absence.

a with dementia in a moment', 'sharing

study from

care psycho-geriatric hospital place but not

dementia
unit moment' and
unit
'sharing neither

place nor moment'.

Fukuda eta al. (2015). To explore the 50 nurses Qualitati Problematic patient Nurses develop

Issues experienced challenges nurses face in from 6 ve study behaviors along with protection plans for

while administering providing care to acute using lack of nursing themselves and for the

care to patients with patients with dementia hospitals focus experience and lack hospital.

dementia in acute in acute care hospitals in in Japan group of organization

care hospitals: A Japan. intervie created issues for

study based on focus ws nurses

group interviews

Jones (2013), An To explore the 8 nurses Qualitati care for patients with The study will help to

exploration of the experiences of nurses with 2 ve study dementia in hospital improve the quality of

challenges faced by and the difficulties they years especially at end of care that patients with
Semi-
nurses delivering end face in caring for a work life remains sub dementia receive in
structure
of life care for patient with dementia experienc optimal despite the
patients with nearing end of life e d various government hospital

dementia in the acute intervie policies

hospital setting. ws

Clissett et al. (2013), To explore the way in 34 Qualitati Health care Person-centred care

challenges which current dementia ve study professionals in should be valued at the

The

achieving approaches to care in patients acute settings are not level of both the
of Observa
acute settings had the aged over taking advantage of individual and the
person-centred tions
acute potential to enhance 70 years all the opportunities organisation/team for
care in and
A personhood in older and their to sustain people with dementia
hospitals: intervie
qualitative study adults with dementia. relatives personhood for to have appropriate
ws
people with care in acute settings.
of people with
dementia.
dementia and

their families
Griffiths et al. (2014). To explore doctors, 11 Qualitati Doctors admitted Training is required

Preparation to care nurses, and allied health medical, ve study inadequate across healthcare

for confused older professionals geriatric, knowledge of mental professionals in the

Semi
patients in general perceptions of their and health disorders UK. Specialist support
structure
hospitals: a study of preparation to care for orthopedi include diagnostic should be increased
d
UK health confused older patients c wards features of dementia.
intervie
professionals. on general hospital in Nurses considered
ws with
wards British training on handling
doctors,
teaching agitation and
nurses
hospital aggression among
and
patients a priority.
allied Communication with

healthca confused patients

re was a challenge.

professi

onals
Roch et al. (2014) To examine how 292 Mixed Caring practices are Systemic interventions

organizational climate nurses methods affected by the are needed to improve

Organizational

and influences patient and 15 study interplay of organizational climate

climate

nurses' outcomes and its effect direct organizational and to support RNs'
hospital

caring practices: on nursing care delivery care climate dimensions involvement in a full

registered with patients and range of caring

a mixed-methods
nurses, nurses practices.
study
nursing characteristics

personnel

and

managers

(2011) To find out what works 700 Structur -Involving family Caregivers and staff
Thompson

works, well, what makes it practition ed members in care is should work as

"What

we difficult, and what needs ers and surveys. beneficial partners

and what

need to do to to happen to support 1484 Staff training should The hospital

improve acute better care for people people be more practical environment should be
with dementia and their with
hospital care" and interactive changed to suit
families in general dementia
patients with
Care plans should be
hospitals and their
dementia.
individualized
caregiver

Sampson et al. (2011) To assess the use of an 33 Intervie Caregivers chose not Nurses should

intervention aimed at patient/ca ws using to make Advanced encourage able

"Palliative
improving end of-life framewo Care Plans due to patients to work with
 and care for patients with regiver rk family conflicts and family members to
assessment

care dementia. analysis an unwillingness to make plans for their

advance
accept the likelihood future care while they
planning in
of future problems. are still able.
severe dementia:

An exploratory Caregivers showed Nursing staff can

randomized an interest in getting provide end-of life
controlled trial of further information education to
a complex about end-of-life caregivers of dementia
intervention" issues and dementia. patients.

Wierman et al. (2011) To assess the feasibility 26 Descript No statistically When working with

of using Simple patients ive significant change in agitated dementia

"Nonpharmacolo
Pleasures interventions with agitation levels was patients, staff and
gical

of in a hospital setting baseline noted. family members

management
dementia appreciate having
agitation in
admitted alternatives to
hospitalized
in restraints and
patients with
hospital pharmacological
late-stage
treatments.
dementia: A pilot

study"

Watkin et al. (2012) To identify the 621 Unstruct Patients with Staff should receive

prevalence of reported people ured delirium or training to help them

"Prospective

cohort study of adverse events involving age of 70 intervie mild/moderate better understand

adverse events in older patients during an years and ws and cognitive dementia, and to
 people acute hospital admission above observat impairment were provide them with
older
who had ions. significantly more information that can
admitted to the
an likely to experience help them care for
acute general
unplanne an adverse event. cognitively impaired
hospital: Risk
d patients
factors and the Staff frequently
admissio
impact of failed to recognize
n to a
dementia" cognitively impaired
general
patients.
hospital

(2011) To demonstrate how 4 case Communication All staff need to work

Webster

"Improving care person centered hospitaliz studies between caregivers together to improve

for people with assessments improve the ed older and nursing staff knowledge and

in care given to dementia adults was impeded due to acquire the skills
dementia

hospital: patients in acute hospital and their frequent relocation needed to care for
acute

of settings caregiver of patient within the dementia patients

The role
s. hospital
person-centered Nurses should utilize
assessment" person centered

assessments

(2011) To demonstrate the 1 nurse at Case Staff members felt Simple interventions
Williams
effectiveness of a new general studies that the program that involve
"Hospital

for program designed to hospital would help them to communication with

programme

dementia specific improve the safety of and 1 better understand caregivers, and the

patients with dementia senior their role in clear identification of

care"
 in a hospital setting nurse providing care to patients with

from dementia patients. dementia, can improve

elderly both staff and family

care ward members hospital

experiences

Cowdell (2010) "The To investigate the 11 people Ethnogr Patients found the Attention should be

older experiences of patients aged 80 aphic hospital environment focused on

care of

with and nursing staff in to 93 and to be difficult and encouraging empathy

people

in relation to the care years old observat disturbing, became in staff who work with
dementia
delivered to and with ion distressed by dementia patients.
acute hospitals"
received by older people dementia unpleasant care

with dementia in an delivery

25 RNs
acute hospital setting.
and 33

nursing

assistants

4. Thematic analysis

4.1. Challenges faced by Nurses when managing dementia patients in a hospital setting

As the number of people with dementia increases, admissions to acute hospitals for treatment of

dementia have also increased. As earlier mentioned, the new hospital environment tends to
aggravate symptoms of dementia in an acute care environment. It is therefore the responsibility

of nurses to minimize the aggravation of dementia in acute care hospital settings by providing

adequate care. Clissett et al. (2013) believe that hospital nurses are highly skilled in handling

acute health needs of patients including the elderly. However, some may lack the expertise

required to help them manage the behavioral disturbances that are common among patients with

dementia. As a result, they may be unable to provide adequate care to meet the needs of the

dementia patients.

Fukuda et al. (2015) argue that most dementia patients are admitted in long-term care facilities or

in psychiatric wards. For instance, according to a study by Fukuda et al. (2015), measures of

dementia care in Japan were mainly focused on nursing support aspects like basic maintenance

of nursing care services and construction of the community care system. For this reason, majority

of dementia inpatients were in psychiatric wards while the rest were in recuperation facilities.

Nurses in Japan therefore had very few opportunities to care for dementia patients before until

recently; hence, they are likely to encounter various challenges in caring for dementia patients.

Some of the challenges that nursing staff around the world face when caring for dementia

patients in acute care hospitals could be as a result of ethically difficult situations. These

situations may lead to abuse, disorderly behavior among the dementia patients, and poor

organization of acute care in the hospital setting (Jones, 2013). Another study by Griffiths et al.

(2014), found that in an effort to provide adequate care to dementia patients in acute hospitals,

nurses face difficulties in regards to responsibility for patients such as frustration due to lack of

organization, working alone, time, and divided tasks among others. At times, nurses are required

to use restraint or force when caring for aggressive dementia patients but lack of assistance from

other nurses leads to frustration.

Problematic behavior of dementia patients in acute care hospital setting

The behavior of dementia patients is highly affected by the new and unfamiliar environment in a

hospital setting along with behavior restrictions. When in a hospital setting, dementia patients

may experience anxiety due to change in environment and when they see unfamiliar faces

(Marquardt, 2011). In addition, physical restrictions and painful treatments and medications may

lead to anxiety. This anxiety may cause problematic behaviors among the patients like wandering

and falling. Since the nurses do not always have an adequate understanding of the patients fall

risk, they may be unable to follow the fall prevention protocols depending on the fall risk of the

dementia patient. This is supported by Roch et al. (2014) who reported that dementia patients

often become angry, aggressive and abusive if they do not see a familiar face for a day but they

tend to feel secure when a family member is present. Dealing with aggressive and violent

behavior of patients with dementia is quite challenging for nurses since they at times become

victims of the patients violence. Nurses who experience this violence can show a high level of

psychological stress, burnout and depersonalization which may reduce their ability to deliver

care efficiently. Evardsson et al. (2012) support that there is a correlation between the working

characteristics of a nurse and the behavioral symptoms of a patient in that a dementia patient who

is cared for by a nurse with low level of job strain has lower incidence of problematic behavior.

Prognosis challenges

Realistic prognosis is crucial in enabling carers and patients to prepare realistic expectations for

either short-term or medium-term course of dementia. However, there are a lot of prognostic

uncertainties in patients with advanced dementia compared to all other serious illnesses.

According to Cowdell (2010), prognostication poses a major challenge to nursing staff since they
have to primarily rely on clinical judgment. In most cases, the nursing staff ends up predicting

time-frames inaccurately by being overoptimistic when in regards to mortality of the patient with

dementia. Cognitive impairment among dementia patients tends to hinder treatment due to the

limited ability of the patient to consent and adhere to treatment (Cowdell, 2010). For instance,

refusing to provide consent may affect the patients health due to lack of enough food and fluids

to maintain their health. Therefore, the nurses have to rely on their own values, beliefs and

clinical judgment regarding the type of care they should give to patients. This inaccurate

reporting along with the values and beliefs of the staff affects the quality of care given to patients

during end-stage dementia.

Lack of support from the patients family

According to Clissett et al. (2013), nurses need the patients family members to assist in care

giving in the hospital but in most cases family members are not available. During hospitalization

and medical treatment of dementia patients, many issues arise such as unhygienic behavior,

dangerous conduct, and inability to abstain food when asked to. Nurses alone cannot solve these

issues and hence they need the assistance of family members who understand the patient

behavior better. Furthermore, in situations where there is a shortage of staff especially at night,

nurses have a hard providing care to patients without dementia because they have to focus more

on dementia patients with problematic behaviors. Thus, lack of cooperation from the patients

family members poses a major challenge for nurses (Griffiths et al., 2014). At times, nurses

develop measures that can help in preventing problematic behaviors from dementia patients so

that they can be able to provide the necessary care, but the measures are not always successful

especially when family members are not available to offer assistance.

Lack of nursing experience and training in dealing with dementia patients

Nurses have the ability to detect signs of problematic behavior among dementia patients early.

They are able to closely observe regular behavior of patients in order to identify small changes in

their daily activities. However, despite early detection, nurses are unable to prevent incidents

related to problematic behavior among dementia patients. Fukuda et al. (2015) explain that every

dementia patient has a unique way of expressing symptoms, which can be hard to understand the

cause. For this reason, nurses have a difficult time preventing incidents among dementia among

patients because they do not understand the cause. According to Mukadam and Livingston

(2012), nurses in most cases lack opportunities to gain knowledge and advice about dementia.

Thus, they mostly learn from their own observations and experiences of how they see the senior

nurses handling patients with dementia.

Lack of cooperation and support among professionals in the hospital

Caring for dementia patients can be exhausting and frustrating for nurses especially due the

complex needs of these patients and the limited time available to meet all needs during working

day (Sanchez et al. 2013). Thus, nurses too need to be cared for through support from the

organization as well as other professionals in the hospital. However, disharmony among health

professionals and flawed organizational priorities pose a lot of challenges for nurses. Biquand

and Zittel (2012) argue that when hospitals put constraints on the requirements needed to provide

care for dementia patients sensitively, they create a gap between what the nurses are capable of

doing in terms of care and treatment and what they feel they should actually do. As a result,

nurses may feel frustrated due to the hospitals constraints that prevent them from delivering
appropriate care to dementia patients. A high level of frustration often leads to stress which is

likely to have a negative impact on the clients self-efficacy and well-being.

Lack of Resources

According to Sanchez et al. (2015), the ability of nurses to deliver ethical care to patients with

dementia may be challenged by the lack of adequate resources. The lack of resources in a

hospital setting affects the nurse-patient ratio since fewer nurses are employed to provide care to

the patients. As a result, the few nurses available feel overworked due to too much workload as

well as other pressures associated with caring for dementia patients. The quality of care, which is

directly linked to nurse-patient ratio, is also affected in that the nurses are not able to attend fully

to the needs of the patients. Moreover, the nurses experience time pressures since they have to

care for many patients at the same time and this increases the chance for medical errors as well

as ineffective care delivery.

Medical interventions for patients with end-stage dementia

Patients with end-stage dementia tend to have poor pain control which makes it difficult to

determine the most appropriate medical intervention for them. According to Wierman et al.

(2011), end-stage dementia has been associated with poor prognosis as well as limited life

expectancy which cannot be improved through invasive procedures. Aggressive medical

approaches have also been found to have limited efficacy. Knowing that they cannot cure or

prevent the progression of most dementias, nurses find it challenging to provide comfort and

good quality palliative care to patients with end-stage dementia. Webster (2011) found that the

use of antibiotics is quite common for treatment of patients with end-stage dementia despite the

discomfort associated with antibiotics and the limited utility. Some hospitals provide non-
palliative interventions during end of life for dementia patients. Webster (2011) blames this on

the inadequate training of nursing staff in discussing end-of-life decisions, lack of advanced

directives and prognosis uncertainties regarding the course of the dementia.

4.2. Challenges faced by patients with dementia in a hospital setting

Lack of adequate support from the nurses

As aforementioned, lack of enough resources affects the nurse-patient ratio in an acute care

setting. Therefore, it is not uncommon to find dementia patients being cared for by overworked

nurses who do not have time to engage in personal interactions with the patients (Blagg and

Petty, 2015). The nurses are often too busy focusing on the physical tasks rather than listening to

the patient. Any complaint from the patient with dementia is considered a symptom of the

disease rather than as a result of incorrect treatment. Lim et al. (2011) refers to this kind of

unsatisfactory relationship between the nurses and the patients as malignant social psychology,

which is shown by care providers who perceive dementia patients as unworthy of engagement.

Dehumanizing attitudes from nurses such as stigmatization, objectification and disempowerment

are some of the ways that nurses demonstrate malignant social psychology. This kind of nurses

also feel disempowered and show lower job satisfaction, which affects how they relate with

patients.

Stigmatization

According to Phillipson et al. (2012), old age and dementia are among the conditions that are

high stigmatized by the society. Stigmatization of dementia patients by nurses as well as other

care providers is apparent in hospital settings although it is less prevalent among nurses who are

more educated and have a better understanding of dementia condition. Nevertheless, Mukadam
and Livingston (2012) argue that some educated health care providers do demonstrate prejudice

against dementia patients. They tend to label and judge patients with dementia which propagates

stigma and influences the attitude of nurses towards the patients thereby affecting the quality of

care they provide. Furthermore, insinuating that the behavioral symptoms of a patient with

dementia are deliberate and hence annoying and irritating to the nurse rather than a symptom of

dementia or an indication of an unmet need could be termed as stigmatization. This is a challenge

that the patients have to deal with especially since the prevalence of negative attitudes towards

dementia is across all levels of society and thus influencing the ability care providers to see

dementia patients as worthy of person-centered care.

Communication

A common misconception that is held by nurses and care providers is that people with dementia

eventually lose their ability to communicate and hence they put very little effort to try to

communicate with patients with dementia in hospital (Moreau et al., 2015). Patients in the early

stages of dementia are very much able to communicate though they require little prompts and

cues to orientation. As the condition progresses, patients begin to experience memory loss, poor

concentration and comprehension, and difficulties finding words, which often lead to distress and

frustration. As a result, the patients ability to express themselves is limited and their confidence

and sense of identity erodes. Furthermore, their ability to connect with others becomes more

difficult and their ability to communicate and understand the needs of others becomes impaired.

This creates a challenge for the patients to communicate their needs and also affects the

relationship between the nurse and the patient especially since the nurse is already facing

challenges relating to time constraints, lack of understanding about dementia and inappropriate

ward environment (Moreau et al., 2015).

4.3 Challenges faced by the family caregivers of dementia patients in hospital setting

Family caregivers also experience certain challenges when trying to provide support to their

loved ones with dementia in hospitals. Despite the positive effects of their support, family

caregivers at times feel overburdened, experience social isolation, psychological morbidity,

physical ill-health and financial hardship. Family caregivers also face a lot of challenging trying

to balance caregiving with other demands such as career, relationships and children. They are

therefore at an increased risk of depression, stress, burden and other health related complications.

Watkin et al. (2012) believes that caring for a dementia patient is usually more stressful than

caring for a person with physical disability.

Nevertheless, it is important for family members and caregivers to offer their support to their

loved ones in hospitals because when dementia patients are unable to communicate their needs or

thoughts, family caregivers are able to provide the necessary information to assist the nursing

staff. They assist with care activities such as dressing the patients, finances, and personal care

among other daily activities. One challenge that family caregivers face is poor communication

with hospital staff. According to a study by Thompson (2011), family carers often have valuable

information to share with the staff regarding the care of the dementia patients but in most cases

their information is ignored. This could be due to the fact that some nurses believe they are the

only ones with the appropriate knowledge to provide care to their patients and not the family

caregivers. Nursing staff also fail to explain to the family caregivers the type of care and

treatments they give to the patients.

There are two models that can be used to explain the challenges faced by caregivers of patients

with dementia. According to the Poulshock and Deimling model, dementia causes a burden of
care that can manifest as a strain in several ways worsening the condition such as behavior

disturbance and psychological and physical ill-health of caregiver or improving it through mature

coping mechanisms and support (Van der Lee et al., 2014). The Pearlin and colleagues model on

the other hand discusses four aspects that lead to caregiver stress. These are the background, the

primary stressors of the illness, secondary role strains and intrapsychic strains (Van der Lee et al.,

2014). In the model by Campbell and colleagues caregiver burden is predicted by role captivity

where the caregiver may feel trapped in their role, caregiver overload which involves burnout

and fatigue and adverse life events that are not within the caregiving role and relationship quality

(Van der Lee et al., 2014).

5. Strengths and limitations

This review had several strengths. To start with, reviewing literature as opposed to going to the

field to gather information about challenges of dementia in a hospital setting saved a lot of time

and funds. In addition, articles were easily accessible through the internet hence there was no

need to visit the library to get the information. However, there are several limitations

encountered during this review. First, only a few articles contained data that was collected

through direct interviews. This is because it was quite challenging to find articles to review that

used direct interviews to collect data from the dementia patients. This could have been due to the

fact that dementia patients experience communication difficulties which make it hard for them to

take part in interviews. Also, it could be due to ethical difficulties associated with conducting

research on vulnerable people who may not be in a position to provide and informed consent.

Moreover, obtaining articles that contained exact information regarding challenges of managing

dementia in a hospital setting was quite challenging. Therefore, most of the articles reviewed in
this study contained data that was closely related to the topic being studied and did not provide

the exact data required. Another limitation is that most of the studies reviewed in this study used

relatively small sample sizes to collect data. A small sample size also does not provide

comprehensive information regarding the subject being studied. This makes it difficult to

generalize the findings back to the larger population. In future, studies with larger sample sizes

should be conducted to provide a deeper understanding of challenges of managing dementia in

hospital setting.

6. Implications for practice and future recommendations

Discussion of findings

One theme that was common among most of the articles reviewed in this study was lack of

training for nursing staff providing care to dementia patients. For instance, one article by

(Cowdell, 2010) stated that the nursing personnel lack the confidence to provide psychological

care to patients with dementia. Sampson et al. (2011) also identified that nurses were unable to

identify cognitive impairment among patients with dementia and therefore could not initiate the

appropriate safety measures to prevent patients from falling and injuring themselves. This is due

to lack of dementia-specific training in acute care settings which is believed to contribute to the

aggressive behaviors among dementia patients. For this reason, Webster (2011) discusses the

importance of staff education so as to help provide appropriate care to patients with dementia.

Another theme that can be identified in the review is lack of adequate support to nursing staff

from family members of patients with dementia and other staff members in the hospital setting.

According the study by Williams (2011), nurses who provide care to patients with dementia often

complain their work is considered as unskilled especially by other medical staff. For this reason,
they receive very minimal assistance from other staff members when caring for patients with

dementia. Family members on the other hand are unavailable, old, or unwilling to assist the

nurses once they take their loved ones to the hospital because they perceive provision of care to

be the responsible of medical staff.

Most of the studies reviewed addressed the importance of effective communication between the

staff and dementia patients. Poor communication between the staff and caregivers was addressed

in an article by Hermann et al. (2015). Family caregivers tend to feel ignored when nurses fail to

communicate the status of the patients with them, which creates distrust and doubt regarding

whether the nurses have any knowledge of dementia or they are withholding information. Article

by Bridges et al (2013) supported that good communication among the staff, the family members

and the patients enhances the quality of care provided to the patient as well as establishes a

strong relationship that is beneficial to all parties involved. Cunico et al. (2012) also encouraged

establishment of good communication between nurses themselves so as to promote exchange of

ideas and experiences in regards to caring for patients with dementia.

Another theme that arose from the articles is lack of good assessment for patients with dementia.

Bridges et al (2013) explain that not assessing the cognitive status of dementia patients has a

negative impact in all aspects of care provided by nurses. If transfer documentation is not made

adequately, it could be challenging for the nursing staff to differentiate between dementia and

delirium. Dewar et al. (2013) suggested that improving documentation can help nursing staff to

assess and make appropriate treatment plan for patients.

When it came to the patients, one theme that arose from the review is disorientating aspects of

hospitals that brought a lot of confusion and problematic behavior. According to a study by
Duffield et al. (2011), some dementia patients were found to be unaware of the new hospital

environment thereby making them alarmed by the unfamiliar sounds and new routines in the

hospital setting. Their inability to comprehend where they were and communicate with the

unfamiliar faces, made them feel powerless and apprehensive, which resulted in behavior

change. They led less social interactions among some patients as they preferred to spend time

alone while other become aggressive and irritable since they did not understand where they were.

Lack of palliative care was also discussed in some of the articles. It is challenging for nurses to

identify pain especially among dementia patients who have lost their ability to communicate.

Therefore, medical interventions for patients with end-stage dementia who have poor control of

pain are quite difficult. In the study by Maben et al. (2012), pain management is thus found to be

inadequate for dementia patients who were unable to express their discomfort. Hospitals tend to

administer invasive procedures to dementia patients near end of life and ignore the importance of

palliative care.

Another theme that emerged during the review is stigmatization of dementia patients by nursing

staff and carers. Milne (2010) found that some health professionals judge and label patients

under their care which is tantamount to stigma. Some nursing staffs ignore the needs of dementia

patients and opt to attend to other patients because they insinuate that their problematic behavior

is deliberate rather than a symptom of an unmet need. Ignoring the needs of a dementia patient

even when one knows that the patient is in need of care can be considered as stigmatization.

Implications of practice

The findings of this study indicate that nurses and other medical practitioners providing care to

patients with dementia lacked suitable measures to tackle problematic behavior among patients.
This study also indicates that they lack appropriate training that can help them understand the

symptoms of dementia especially among patients who have lost their ability to communicate.

Furthermore, according to McSherry et al. (2012), hospital staff lack the confidence in their

abilities to offer care to patients with dementia, struggle to communicate effectively, and avoid

psychological aspects of care provision. It is therefore important that all hospital staff receive

regular training on dementia so as to enhance their understanding of dementia and dementia

patients and to explain the possible safety hazards which could occur as a result of working with

these patients. Several studies conducted in nursing homes and long-term care facilities have

found that staff training programs are effective in tackling problematic behavior among dementia

patients. For instance, one study by Williams (2011) revealed that using staff training programs

in acute care hospitals provides an education system through which nurses can be trained on how

to conduct observations to identify problematic behavior among patients and develop coping

methods.

At times, as seen in this study, nurses find themselves in situations where they need the

assistance of family members of the patients with dementia so that the can be able to take care of

other patients without dementia. However, in most cases family members are not available or are

unwilling to assist since they believe that care provision to patients is only the job of nurses and

other medical practitioners. Other staff members are also not willing to help due to the

misconception that dementia is not a disease. Therefore, it is important for hospital managers to

coordinate other staff members to assist in providing care so that nurses do not have to request

for help from the families of the patients. Staff members should be trained to understand that

dementia is a disease like any other and that patients with dementia need specialized care and

support from all staff members. Webster (2011) found that patients with dementia tend to benefit
more when all staff members work together to provide the best care. In addition, problems

associated with problematic behavior of patients with dementia would be detected early and

prevent as well. The nurses would as well get more time to care of other patients.

In regards to stigmatization of patients with dementia, a holistic approach is required to educate

communities in the UK regarding dementia. Hospitals have a role to play in educating their staff

from porters to doctors so that they can embrace dementia care and ensure that all staff members

consider dementia patients their responsibility (McSherry et al., 2012). By doing this, hospitals

will ensure that any staff member who comes across a dementia patient will be able to provide

quality care since they all have adequate levels of training and awareness. Since the negative

attitudes towards dementia penetrate all levels of the society thereby influencing the health

professionals ability to provide appropriate care to patients, activities where the community

works together with the hospital could be of great benefit in reducing stigmatization of dementia

patients. For instance, local-based therapists could provide music therapy and reminiscence

workshops with patients with dementia in order to encourage a better understanding of dementia.

Students and other residents could also organize to visit dementia patients in nearby hospitals.

As seen in this study, the hospital environment influences the behavior of dementia patients.

Therefore, getting the environment right is very important. Refurbishments need to be done to

make dementia patients feel more at home than in a hospital. This study indicates that use of

clear signage and visible clocks can help to improve the patients orientation in the hospital. This

may not only involve the physical environment but also the level of emotional support to the

dementia with dementia.

Future recommendations
It is important for nurses to provide individualized care to patients with dementia. Stigmatizing

the patient can affect the quality of care provided and also have a detrimental effect on their

health. Therefore, it is important for nurses to treat people with dementia in a humane way by

taking time to talk to them, establishing strong relationships with them and assessing their needs

carefully. This may make the patient feel valued and appreciate the nurses more. Given that the

hospital environment usually adds to confusion and disorientation of a person with dementia,

making significant changes to the environment can have a beneficial effect on the dementia

patient (Moyle et al., 2011). This may include using signage that are easy to read and large

clocks and calendars to help orient patients and reduce confusion in the hospital.

Lim et al. (2011) believe that effective communication is a very important aspect of care for

dementia patients in a hospital setting. Lack of effective communication can make patients feel

ignored and find it hard to communicate with caregivers when they are unsatisfied with the care

being given to them. It necessary for hospital managers to encourage successful dialogue

between all medical staff and patients so as to establish beneficial relationships, improve patient

care, and increase customer satisfaction. It is also important to encourage communication among

staff members in order to promote effective nursing care (Lim et al., 2011). This promotes

sharing of ideas among staff members that can be valuable tools of learning.

Fukuda et al. (2015) found out that patients with dementia in hospital settings are rarely assessed

to identify their cognitive status, which affects the quality of care provided. It is important that

the cognitive status of all patients with dementia is assessment regularly during admission so that

they provided care is provided to the patients. For instance, patients who are unable to

communicate effectively should have pain assessments conducted regularly in case they are

experiencing discomfort. It is the responsibility of nurses to advocate for such patients by

assuming that the patients maybe experiencing pain especially during painful procedures and

hence provide appropriate analgesia for them.

Many hospitals ignore the important of effective end-of-life care for patients with dementia

(Fukuda et al., 2015). Nurses should always prepare to provide palliative care to end-of-life

dementia patients, help to control pain and prevent other distressing symptoms like dyspnea.

This may require the nurses to know the religious preferences of the patient as well as provide

necessary spiritual support to the family members to comfort them during such as difficult time.

It is therefore necessary that nurses are provided with skills to share knowledge about end-of-life

when appropriate with family members so that they can plan for future.

In regards to future research, there is a need to conduct further research focusing on the

experiences of hospitalized patients with dementia. Most the articles reviewed in this study

focused on UK and a few on Asia and United States and this provided limited research for the

study. In order to get more comprehensive data that can be generalized to the larger population,

future research should focus on patients with dementia in hospital setting in other countries as

well. Moreover, future research needs to be based on ethically sound methods of research that

include patients with dementia and allow them to be heard. This is because without hearing the

point of view of the patients, it is hard to evaluate interventions that are designed to improve

their hospital experiences.

Conclusion

This study has provided a review of literature regarding the challenges of managing dementia in

a hospital setting. As life expectancy continues to increase, the elderly population is also growing

and so is the number of people suffering from dementia. People with dementia are hospitalized
due to several reasons including the need for special care and observation that family caregivers

may not be able to provide. The challenges of managing dementia in a hospital setting are not

only experienced by the nursing staff but also the family caregivers and the patients themselves.

In alignment with the findings of this study, the main challenges faced by the nursing staff

include lack of support from other health professionals in the hospital, problematic behavior of

dementia patients, lack of adequate support from the family care givers, lack of resources,

prognosis issues, medical intervention difficulties, and lack of clear understanding of dementia

due to insufficient training. Challenges faced by dementia patients in hospital setting include

poor communication, lack of adequate support from nursing staff and stigmatization. Family

caregivers also face communication issues, and feeling overburdened due to caring for the

dementia patients in the hospital along with other daily activities at home.

Therefore, based on the findings obtained from this review, training is important for all hospital

staff to promote a better understanding of dementia and encourage staff to provide necessary

support in caring for the patients. Training should help nurses not only to broaden their

knowledge about dementia but also to develop cognitive and pain assessment skills during end-

stage dementia. There is a need to improve communication between the nursing staff, the

patients and the caregivers in order to ensure adequate care and satisfied patients. Individualized

care should be provided to establish trusting relationships between the nurses and the dementia

patients.

There current literature regarding dementia does not focus on patients; hence, efforts should be

made to find ways through which dementia patients should be included in studies in future.

Moreover, very few studies have been conducted in hospital settings which is where most
dementia patients are. Most of the current studies have been done in specialty dementia care

environment; thus, future studies should be conducted in hospital setting to give a different

perspective.

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